Plexis Healthcare Software for TPAs

A Third Party Administrator(TPA) is an organization that performs benefit administration and claims processing services for other organizations, like self-funded employer groups. However, TPAs may contract with insurance companies and managed care health plans to perform these same services on their behalf.

Plexis Claims Manager claims processing and benefit administration software helps Third Party Administrators (TPAs) reduce their workload and costs and add value to their client services. Plexis Claims Manager's rule-based claim processing system typically creates 90% auto-adjudication rates, which means that only 10% of all claims processed require manual intervention.

Plexis software solutions for TPAs reduce steps in every area of claim processing and benefit administration. You can manage member enrollment, provide instant and accurate information to call centers, generate flexible reports, adjudicate claims in seconds, and administer contracts in a few keystrokes. Your staff will accomplish more in less time with Plexis Claims Manager benefit administration and claim processing software for TPAs.

Plexis Supports Benefits Administration Services Provided by Healthcare TPAs

• Premium billing (to the employer, to excess loss carriers, etc.)
• Commission processing/payment (to agents and brokers that bring groups to the TPA)
• Enrollment (loading employees and their dependents into the TPA's system, generating ID cards, sending out letters [approved, denied coverage, etc.])
• Claim processing (receipt, settlement, payment)
• Customer Service (taking/logging of calls from members, providers, plan administrators, etc.)
• Case Management (medical management, UM/UR services aimed at managing the care of the employees and their dependents in an effort to keep utilizations expenses down; often billed to the employer group on a PEPM basis)
• PPO Brokering/Negotiation (bring PPOs and employer groups together, may provide out-of-network fee negotiation with other PPOs on the employer's behalf)
• Excess Loss/Stop-Loss coordination (report to and coordinate with excess loss carriers for claims that exceed the pre-determined "shock-loss" (individual claim) or "stop-loss" (group) amount)

Plexis Supports TPA Claim Processing and Benefits Administration Workflows

• Use of PPOs for claim repricing. In some cases, TPAs will not have access to, or will not load an external PPO's fee schedule(s) into their claim system, so claims are sent off to the PPO for repricing.
• When not working with a PPO, TPAs will often use the UCR payment methodology for pricing claims, as direct provider agreements typically do not exist. UCR is a contracting standard in place that both sides (employer/TPA and provider/provider network) can agree upon.
• Will work with an external pharmacy benefit manager ("PBM"), which is a TPA that administers RX benefits and claim payments. The TPA will receive encounter data back from the PBM to share with the employer.
• Provides various stop-loss/shock-loss reports to both the employer and the excess loss carrier.
• Serves as an extension of the HR department at the employer group to provide additional employee benefit administration services, such as COBRA benefit administration, short-term disability ("STD"), long-term disability ("LTD"), workers compensation, Section-125 (cafeteria plan)/flexible spending account ("Flex"), health reimbursement accounts ("HRA") and health savings accounts ("HSA").

Healthcare TPAs also benefit from Plexis EDIWorks, which eliminates a great deal of paper-based processing and improves the efficiency of electronic data interchange by integrating healthcare information directly into the Plexis Claims Manager database. EDIWorks' XML Translator allows TPAs to apply their own business rules to the electronic data, creating a seamless flow of information into the database.

Plexis WEBWorks is offers Healthcare TPAs a complete web tool set that provides control of the online process and allows TPAs to manage a client's information, view progress, and share information with al plan vendors. Plexis WEBWorks puts the Healthcare TPA in control of both the users of information (members, plan sponsor, providers, agents, brokers, stop-loss carriers) and the content they are authorized to view. By entering a registered name and password, medical providers verify benefits, check claims status and access payment history of previously submitted claims.

Plexis WEBWorks also improves customer service for Healthcare TPAs. By providing information over the member and provider information over the Internet, WEBWorks eliminates the unnecessary call center activity and saves time and money.

Plexis WEBWorks also adds value to Healthcare TPA's client services with comprehensive reporting capabilities. Plan cost modeling and other forecasting features help Healthcare TPAs retain clients, reduce costs and increase efficiency.

Plexis WEBWorks also adds value to Healthcare TPA's client services with comprehensive reporting capabilities. Plan cost modeling and other forecasting features help Healthcare TPAs retain clients, reduce costs and increase efficiency.

• Premium billing
• Commission processing/payment
• Enrollment
• Claim processing
• Customer service
• Case management
• PPO brokering/negotiation
• Excess loss/stop loss coordination
• Quoting/renewals
• Use of PPOs for repricing claims
• Pharmacy benefit management

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